Practice beyond the microscope, a memoir: My years as a doctor’s doctor

In South Carolina, an unusual patient presented to our outpatient laboratory, a Champion Stud Spaniel. Obviously old, yet regal, he was miserable with a seemingly untreatable ear infection with creamy pus draining from both ears. In spite of numerous injected and oral antibiotics administered by multiple veterinarians, there had been no relief. His loving master could no longer watch him suffer with endless pawing at his ears. He was scheduled to be put down. One of our doctors directed them to me and my pathology laboratory with kind words of hope. The first task was easy: Discover the bacterial cause of this obvious infection. We knew from the exam that it was a virulent bug and one not likely responsive to common antibiotics. Our cultures quickly confirmed that suspicion, identifying a potentially effective therapy, but we were reminded to respect the basics of dealing with infection: Drain when possible and irrigate the wound, if possible, to physically lift the infection and its products from the site. The hero in this case would be simple hydrogen peroxide and patiently, gently, and wisely wielded Q-tips. This classic approach quickly gave us encouragement during our daily visits. Our revered canine’s caring master learned the lessons with dedication. As the debris cleared, now we could directly administer the carefully selected topical antibiotic of choice for the Pseudomonas bacteria into the ear canal. The lessons learned: When challenged, go back to basic principles. They are, after all, basic because they are truth.

One fascinating case in my early practice involved a young Black male who was bleeding profusely into his urine. We became involved in transfusing him. We learned that the urologist was planning to resect one of his kidneys that had been identified as the source of the hemorrhage because there was no other known approach. His problem was that he had sickle cell trait and it had been learned that, not uncommonly, such patients, owing to the low oxygen concentration in the renal papillae, would develop sickling in the capillaries, leading to infarction and renal papillary necrosis with life-threatening hemorrhage. It was a no-win situation. Further, upon reading recent literature on the subject, it became apparent that after resection of one kidney, it was known to recur in the sole remaining kidney. Resection of both kidneys was not an option. A treatment had been devised that was experimental and potentially life-threatening involving the gradual infusion of epsilon-aminocaproic acid. This would inhibit the enzymatic fibrinolytic activity in the renal papilla, which promoted the bleeding and prevented fibrin from stanching the flow by clot formation. At that time, there were few subspecialists in that community, and when the urologist declined to administer the critical infusion, which required constant monitoring and termination as soon as the bleeding was controlled, I became the default clinician. It worked. The young man recovered completely. Later, I read that the drug had been withdrawn for safety reasons. It is now approved as Amicar for treating intravascular fibrinolysis. I had become the doctor who needed a doctor’s doctor.

In the early years of my practice, it became apparent that the field of endocrine testing was a frequent problem. In those days, screening for adrenal abnormalities typically relied on highly imperfect collections of a day’s urine for the measurement of “hydroxy and ketosteroids.” When dealing with perplexing patients in response to clinicians’ queries, I realized we were measuring metabolic degradation products of the hormones that really mattered, cortisol and other specific steroids such as testosterone. This became possible in a timely fashion as the technique of the radioimmunoassay was just evolving. We had begun exploring the utility of direct cortisol measurements using fluorometry. While this was an advance over the older methods, it remained limited. With the specificity and sensitivity introduced using the radioimmunoassay, we now had rapid and specific assessment of the hormone level. What became apparent was that the static level of one measurement was not sufficient. We learned of the value of obtaining a baseline followed by administration of a stimulus, the ACTH testing protocol, which was the prototype for a range of testing strategies of either stimulation or suppression for many common endocrine disorders. Our experience evolved into a stimulating partnership with an endocrinologist whose office we served with our outpatient laboratory, Nelson Watts, MD, now professor of medicine at the University of Cincinnati. Together, we published a practical guide to endocrine testing through several editions.

The experience with adrenal testing was paralleled with even greater efficacy in thyroid disorders by the progression from measuring the protein-bound iodine to measuring thyrotropin (TSH) eventually with the highly sensitive TSH assay, which came to define both hypo- and hyperthyroidism.

Another unusual aspect of being a consultant to other physicians came in my time at Miami Beach’s St. Francis Hospital. The large retirement community of the elderly became lovingly known to our nurses as “God’s waiting room.” Death and dying were issues needing attention in the ’70s, and Elisabeth Kübler-Ross addressed them well in a secular form. We dealt with the ethical issues of disease and dying in the elderly. While dealing with death, usually the pathologist is principally involved with the autopsy. Our role in the medical staff, however, is central to the practice of medicine in a hospital environment; consequently, I became involved from the medical ethics perspective of death and dying. When is a person dead as opposed to experiencing profound depression of the brain, and what are the signals of the dying process? How are we, as a civilized society, to respond? Fortunately, having been trained in ethics at Villanova and later at Georgetown, I had a foundation upon which to develop. By good fortune, our chaplain held an advanced degree in bioethics, as the term became known. We formed a multidisciplinary team with nurses and administrators, and this team created an Institute of Bioethics for the Florida community. Presenting many conferences and grand rounds provided us a platform for contributing on this subject, again outside of the usual pathology environment, but responding to the call of other doctors for the “doctor’s doctor.” 

Dr. Keffer began practice in the U.S. Air Force in 1962 after internship. He practiced pathology for 33 years. He retired in 1997 from the University of Texas Southwestern Medical Center, Dallas, after serving as director of clinical laboratories at Parkland Hospital. He lives in Murphy, NC.